Outline

Background and aim: With an increasing number of drugs in the pharmacotherapy of elderly, multimorbid patients it becomes more and more difficult to meet conflicting objectives: guideline-based drug therapy, optimisation of the therapeutic benefits for the individual patient, and achieving adherence of the patient to a complex drug regimen. Although these problems affect a growing number of patients (in general practice) there are no clear recommendations or guidelines for family physicians on how to prioritise the drug therapy and reduce polypharmacy in elderly multimorbid patients. Our aim was to develop a prioritisation concept which is feasible in general practice.

Material and method: We did an extensive literature search in different fields with potential relevance to prioritisation in drug therapy: clinical guidelines, pharmacological analysis of polypharmacy, measurement of polypharmacy and of safety problems, studies on patient involvement and shared decision making.

Results: We did not find a prioritisation model which includes all potentially relevant aspects for the priorisation of drug prescriptions. A procedure to prioritise polypharmacy in general practice must involve the patient (resp. care-giver) and has to cover three dimensions:

patient priorities, his perceptions of medication, and the maintenance of concordance.

In the literature we found studies which contained evidence, measurement tools, and guideline recommendations for the first dimension only. For the assessment of the pharmacological appropriateness of prescriptions, decision aids and electronic prescribing assistance are available for the physician, whichare most likely feasible in general practice.

Concepts and tools for the two other dimensions are scarce and need to be developed urgently.

The proposed priorisation model will cover all three dimensions and gives patients the opportunity to include their preferences and treatment objectives into the decision making process.

Conclusion: A first draft of the PRIMUM model will be implemented and pilot tested in 2009. In this pilot phase, our aim is not to generate a 'perfect' prioritisation tool for general practice, but to take first steps in this direction.